The dawn of a new year represents a logical time to look at current business operations and commit to making improvements. One key area that physician practices should focus on is compliance.

There are a myriad of rules and regulations of which practices must be aware. For example, with the ICD-10 code set in place, there are new and expanded coding guidelines. Similarly, organizations have to have strong procedures for safeguarding proper medical waste disposal, worker safety, and patient information.

Compliance in these areas can fall short, especially in smaller practices that have limited resources, and consequences can be severe, ranging from financial penalties to blemishes on a physician practice’s reputation. Organizations cannot afford this negativity given the competitive and costly nature of healthcare today.

Although keeping up with the multitude of regulations may seem daunting, it does not have to be. Even though different government requirements touch on diverse topics, organizations can take a similar approach to meeting all the rules. Not only is this cost effective, it also ensures that nothing slips through the cracks.

The following are some key resolutions that practices can make to commit to and execute upon a strategic compliance plan:

Appreciate the scope. First and foremost, physician practices must familiarize themselves with the applicable regulatory requirements. Getting a firm grasp on what an agency mandates is vital to understanding the extent of necessary compliance efforts. For example, two critical Occupational Safety and Health Administration (OSHA) regulations are the bloodborne pathogens standard and the hazards communications standard. These rules dictate that organizations must have detailed written policies that outline the risks present in the organization and describe how the practice plans to address those risks, including needlesticks, exposure to dangerous chemicals, and so on. On top of these two main standards, OSHA has other requirements that relate to personal protective equipment, hazardous chemicals, workplace violence, ergonomics, and so on. Like many other compliance areas, OSHA offers information about what’s required on its website, however, this can be overwhelming and a little unwieldy to navigate. Practices should look for resources, including consulting firms and online tools, to bring the regulations down to size.

Perform a gap analysis. After getting a handle on what’s required, the practice should compare its current performance against the applicable regulations to identify any holes. This may involve performing an in-depth review of existing policies and/or observing operations. In the case of HIPAA, an organization may also want to have conversations with staff about how they maintain patient health information security. Although a physician practice can do some of this on its own, an outside resource, such as a software program or other side-by-side comparison tool, can ensure the assessment process can be more thorough.

Provide training. Once a physician practice identifies compliance gaps, it should work to implement strategies to address them. Training is often necessary at this stage because it builds awareness with staff and can alter behavior so that the organization becomes more consistently compliant. For example, targeted staff training can help with coding compliance in that it demonstrates which codes a practice should use when and why. Training can take many forms, but should include real-world examples and opportunities to practice. To make sure staff retain information long term, facilities can employ knowledge retention strategies, such as periodically quizzing staff on certain compliance situations or having them engage in sample exercises.

Updating policies. Another applicable resolution for closing compliance gaps is to verify that the practice has all the appropriate policies in place and these documents contain the right level of detail. OSHA, in particular, is keen on whether an organization has comprehensive policies and whether the facility regularly reviews them. Even if a physician practice experiences a compliance breach, the regulatory agency may be more sympathetic if the practice can demonstrate that it has the correct policies and is aiming to consistently follow them.

Gain staff feedback. Staff can be a valuable resource in compliance efforts, and organizations should empower individuals to speak up about any perceived hazards or ways to improve compliance efforts. For example, if a staff member feels that waste disposal procedures are sub-par, he should feel comfortable bringing his concerns to practice leadership, and there should be an established method for securely and safely expressing opinions. Periodically surveying staff to get their thoughts and impressions is also a good idea. One thing to keep in mind is that employee concerns should be — at the very least —acknowledged, if not directly addressed. If a staff person shares feedback, but feels that nothing ever comes of it, he or she may be less likely to report concerns in the future.

Now, more than ever, is a good time to commit to renewed compliance efforts. By taking a strategic approach, organizations can meet the bevy of requirements while keeping costs in check—something that will ensure a better and safer environment as well as long-term practice viability.

If you're not happy with your EHR system, making a change is not easier said than done. Take some time to weigh the pros and cons before a making this big decision.

"The advantage of keeping a sub-par EHR is that you don't have to go through the arduous process of changing EHRs," says Wanda is also president of the American Academy of Family Physicians. "However, one of the biggest disadvantages of keeping an EHR you don't like is that it tells the staff that they're not worth the investment in a better solution. Don't avoid making a switch because of the effort involved or the money you've already spent."

The advantage of making a change is that you'll hopefully pick a system that's more compatible with your needs. "Because you have the experience of what doesn't work in your current system, you can look for one that works better for your needs,” says John Meigs, Jr., a family physician at Bibb Medical Associates in Centreville, Ala., who is president-elect of the AAFP.

Filer's organization ultimately decided to change EHRs because, "the software was an unmitigated disaster. It was an incredibly expensive and time-intensive project to undertake, but I'm absolutely glad we switched EHRs."

Meigs, who has supported the use of EHRs for more than 20 years, hasn't liked any of the EHRs he's used. "Our current system takes too many clicks to do basic things, and the data isn't displayed in a way that is useful for patient care," he says. "The advantage to sticking with the devil you know is just that — you know what issues, challenges, and hassles you have to face."

The Office of the National Coordinator for Health IT (ONC) has released a full document containing health IT policy levers on its website, giving various healthcare professionals access to different ways states leverage health IT to increase accountable care.

The document, entitled the State Health IT Policy Levers Compendium, reportedly lists nearly 300 different health IT policy levers and explains how states are able to use them to advance the use of health IT, interoperability, and system delivery reform.

For example, the document starts off by discussing how accountable care organizations (ACOs) can work to leverage different health IT policies. ACO payers such as Medicare or Medicaid within different states can require participants to use an interoperable EHR or participate in a health information exchange (HIE).

State entities contracting with providers for participation in an accountable care arrangement can align provider requirements with activities supporting interoperability. For instance, providers may be required to demonstrate they have adopted interoperable health IT or are participating in a health information exchange service in order to participate in the arrangement. Providers who can demonstrate adoption of interoperable health IT could also be provided with opportunities to earn greater rewards/access to shared savings under the terms of the arrangement.

These policy levers work by incentivizing different health IT capabilities. When the states implement certain health IT requirements, or create rewards for using different capabilities, they support the impactful adoption of health IT. All in all, this can help advance the triple aim of healthcare for better care, better spending, and better patient health.

“A health IT policy lever can be defined as any form of incentive, penalty, or mandate used to effectuate change in support of health IT adoption, use, or interoperability,” ONC writes in aCompendium overview. “This tool will help advance the country toward a delivery system with better care, smarter spending, and healthier people.”

The Compendium lists several different healthcare programs that can leverage health IT, and shows that many of them can help advance interoperability. For example, state appropriated funds can be focused on statewide HIE programs, or state lab requirements can include provisions regarding interoperability.

Some of the initiatives can also be leveraged to improve quality care and patient safety. State insurance commissioner policies can be focused on care quality through meaningful adoption ofinteroperable health systems. Additionally, state privacy and security policies can include provisions that “allow for more computable privacy while ensuring appropriate data is protected and shared.”

In addition to describing different potential policy levers, ONC lists the different states that have already embraced such levers. For example, when describing the state privacy and security policies, ONC reports that 16 states have already adopted that lever, including Alaska, Arizona, Arkansas, Colorado, Illinois, Iowa, Maryland, Michigan, Minnesota, Nebraska, New Hampshire, North Dakota, Rhode Island, Texas, Utah, and Wisconsin.

The compendium also has several limits. In lacking a full examination of how these different policy levers have worked for the states, the compendium is limited in giving a truly meaningful list of policy suggestions. Additionally, ONC acknowledges that its data sources are limited, and that state policymakers should consult other data sources in order to get a full view of how different policy levers would work to better their health IT use.

In all, the ONC hopes to continue to build on this document as the varied uses of health IT continues to grow. This will help ensure that states adjust their policies with each change that the industry sees.

“ONC expects to maintain the Compendium via periodic updates,” ONC writes in its document overview. “This initial launch will serve as a foundation upon which ONC will work with states to update and refine the information in the tool. It will also allow ONC to make improvements to the structure and possibly the format of the Compendium.”

Four general policies and developments could help speed up the interoperability initiative.

As a part of a federal mandate to improve EHR use, interoperability, and connected care, the Health IT Policy Committee (HITPC) has submitted its December report to Congress explaining barriers and policy suggestions with regard to interoperability.

Develop Health Information Exchange (HIE) Measures

The first policy suggestion the HITPC explained to Congress was the establishment of HIE-sensitive measures which would not only measure the amount of information providers were exchanging amongst one another, but the meaningfulness and impactfulness of that information. In order for providers to receive high scores on these measures, the information exchanged would need to be used meaningfully, as to reflect an important use of the information.

“In order to enhance the strength of incentives that drive interoperability, a set of specific measures should be developed that focus on the delivery of coordinated care, facilitated by shared information across the entire health team (including the individuals and families) and throughout the continuum of care settings,” the HITPC explained. “An example of an HIE-sensitive measure would look at medically unnecessary duplicate testing.”

This new policy could be effective in strengthening incentives by first allowing payers to incorporate these measures into their payment methods, and second by integrating these measures into public reporting that would in turn reveal which providers give the highest level of coordinated care.

Develop Vendor HIE Measures for Certification

Just as providers should be tested against certain HIE-sensitive measures, as should vendors. Such measures could potentially serve as a direct catalyst to improve vendor developments and performances.

Specifically, HITPC is looking for these measures to occur in practical use -- not in a lab -- and to take into account needs that go beyond certification measures for the EHR Incentive Programs.

“Today, purchasers of EHR systems lack such measures to inform purchasing decisions or to use as a lever to put pressure on vendors to improve,” HITPC confirmed. “Although vendors have strong incentives to pass the interoperability requirements for EHR certification, this process is “one-time” and occurs in a lab. It has not been shown to translate into interoperability that is affordable or easy to implement in the field.”

HITPC also listed a few specific measures that could record vendor HIE performance:

Number of data exchanges from external sources, which could include other providers, community social-service organizations, consumers, payers, etc. (denominator that measures ability to exchange data with another electronic system such as an EHR, HIE or consumer application (app));

Percentage of time viewing of external data changed current activity (e.g., appeared in clinical decision support, led to change in order being written), which demonstrates impact of external data.

Accelerate Incentive Payments for Interoperability

HITPC maintained that in order for providers and vendors to make interoperability progress, they must have adequate incentive payments. Not providing incentive payments encourages providers to deal with internal needs rather than prioritize interoperability.

Today, the lack of palpable financial incentives for interoperability favors the status quo. Pressing internal priorities compete for attention and resources are needed to achieve interoperability, especially when specific actions to enact interoperability are complex and time-consuming. This results in slow progress. Moving interoperability up the priority list will likely take financial incentives that are more targeted than a broad shift from fee-for-service to pay-for- 17 value. To have the desired effect, the incentives must be strong and specific, with clearly defined measures and a deliberate implementation timeline and effective dates.

Initiate Sustained Multi-Stakeholder Action

In order for the above-mentioned goals to be met, HITPC explained that multiple stakeholder groups will need to take action in the overall interoperability efforts. Several of the policy suggestions, such as creating HIE-sensitive provider measures, require multiple voices for development, and multiple interpretations of the ONC Interoperability Roadmap.

Thus, HITPC suggested creating an interoperability Summit of various industry stakeholders in order to collaborate on interoperability efforts.

The output of the Summit would be an action plan with milestones and assigned accountabilities for achieving the milestones in the context of this larger interoperability initiative. We expect the compelling call-to-action would engage the stakeholders to continue their activities after the Summit as a way of meeting the payer-driven incentives that reward HIE-sensitive measures of coordinated care.

Earlier this year, Congress requested a report from the Office of the National Coordinator for Health IT (ONC) which detailed the issues surrounding information blocking. In the report, the ONC both defined information blocking as a practice, and provided examples.

Specifically, ONC defined information blocking as using criteria of interference, knowledge, and lack of justification for refusing to share information.

The information provided in this most recent report from HITPC could potentially put an end to those negative information blocking practices by providing incentives for fostering HIE and interoperability. Between monetary incentives and a clear prescription of HIE measures, both providers and vendors could ideally implement more effective interoperability strategies.

EHR optimization projects are set to be an industry focus in light of the increased adoption of health IT. This focus is perhaps a natural transition, as providers are realizing that just because a healthcare organization adopts an EHR does not mean they are gleaning the most they can from it.

EHR optimization strategies are important options for organizations to look into. Optimizing an EHR system can help enhance a healthcare organization’s revenue cycle, patient care, or even contribute to better clinical analytics, depending on the focus of the optimization project.

In fact, studies show that EHR optimization is slated to be one of thehighest priorities for healthcare organizations in 2016. As more organizations complete EHR adoption and become comfortable with their systems, they see that it is time to develop strategies to better use this technology.

Below, we list the best strategies for beginning EHR optimization.

Reassess your EHR system

When organizations adopt a new EHR, it is natural that they learn the bare basics and take some time to adjust to using the new technology. However, after using the EHR for a while, it is important to reassess how the system is working within the care setting and looking for ways to more impactfully use it.

To begin EHR optimization, organizations should examine how the EHR has functioned within the organization thus far. IT staff can look at how the interface is functioning, financial support can examine the revenue cycle payoff the system yields, and physicians can examine the system’s clinical effectiveness.

From there, staff can develop optimization plans centered around the organization’s goals. For example, if an organization wants to optimize its EHR to improve revenue cycle results, it can concentrate on optimizing the system for clinical documentation and coding improvement.

Identify staff needs

Although looking at EHR outcomes to determine opportunities for optimization is important, it is also useful to consult with EHR users to find user-oriented optimization solutions.

Emory Healthcare is an example of this approach through its recent physician-facing EHR optimization project.

As Emory Healthcare CMIO Julie Hollberg, MD, explained to EHRIntelligence.com in a past interview, the EHR provides a great framework for physicians, but optimization is important for teaching them how to engage with the interface and the information on it.

"The technology like many things does amazing things, but it’s just a tool. You have to learn how to use it just like everything else. We have coupled this with required training so that people have a skeleton from which to hang new knowledge from the coaches when they are in clinic," Hollberg explained.

Also important to user-facing optimization is strong support, according to Hollberg. Emory made sure there was consistent communication between operations staff and users to ensure adequate optimization.

"During the week of go-live we have twice a day conference calls with the physician lead, clinical operations and administrative practice leads to go over the ongoing list of what the issues are and be able to react to those real time," she noted. "The week after go-live, we move from move from twice a day conference calls to three times a week.

However, the coaches are there on an ongoing basis and have a daily meeting or debrief and issues that are a problem are escalated to us."

Carefully cultivate your EHR optimization team

Although EHR optimization sounds as though it could primarily engage the EHR vendor, it is in fact a multi-disciplinary effort. Impact Advisors’ Physician Executive Tanya Edwards, MD, MMM, told us in a recent interview that it takes several team members to implement an EHR optimization strategy.

“Definitely, there is vendor involvement as far as improving usability. But there's a lot that's involved just from an individual organization standpoint,” Edwards explained. “There is a lot that health systems can do themselves as far as usability, taking a look at what those workflows really are. Sometimes, that involves looking at the clinical workflow, streamlining it, and then having IT support that. But sometimes it's really just inside IT and how you choose to build within the product.”

Although the optimization team should ideally be multi-faceted, Edwards told us that these teams should be led by operations experts who will not only be able to accurately execute the work, but direct where the work should go next.

“It is a multi-disciplinary team that needs to be operationally-led because it is the people doing the work who understand the work,” Edwards said. “They understand why things need to be done in a certain order. They understand what the barriers are. Once those workflows are developed, then it's up to IT to come in and try to support that.”

As stated above, several industry experts predict that EHR optimization will be a main focus for healthcare organizations in 2016. Because of the lack of major project slated for the upcoming year, Edwards says she agrees with those predictions.

"It seems like we may have an opportunity in the next year to have a breather, be able to focus a little bit more on being able to optimize these systems, and really try to get the value out of the millions and millions of dollars that we have put in."

Planning and execution efforts toward successful ICD-10 implementation have been the largest resource-intensive undertaking by healthcare in decades. The last couple of years have enlisted dedicated planning by government agencies, healthcare plans, EHR vendors, and health information educators in facilitating the transition from ICD-9 to ICD-10.

The cost of ICD-10 preparation was a valid concern for healthcare. Physicians and other qualified healthcare providers were impacted financially with making initial capital investment in certified EHR systems. The cost of initial training for their private clinics or group practices added to expenditures. Time and resources have been allocated to electronic data exchange testing over two fiscal years in anticipation of possible system interface and program incompatibilities. Concurrently, healthcare professionals had prepared for the code system changes by participating in provider-to-vendor testing while EHR companies, clearinghouses, and healthcare plans have been focused on vendor-to-payer data transmission.

The healthcare industry had ample time to analyze the factors that currently affect efficient and uninterrupted quality healthcare, but have healthcare providers anticipated the factors that will affect their practices after implementation?

A national effort to transition to a new and improved, but vastly different coding system inevitably affects various groups and multiple healthcare transactions. As a result of inaccurate data capture and delays in medical billing, it is critical that providers and administration examine how ICD-10 impacts patient care and reimbursement.

There are different factors that contribute to inferior health data reporting and to delays in provider cash flow:

INACCURATE DATA CAPTURED

1. EHR keywords tend to mimic the alphabetic index of the code book and are not set up in user-friendly clinical terms. Physicians and other qualified healthcare providers may have difficulty in locating the most specific and accurate ICD-10 code when using keyword search and look-up tools in their EHR.

2. Physician documentation practices may not correlate to main terms and subterms in which the ICD-10 code book or electronic code books are organized, making it more challenging for coders or other designated staff members to find the most appropriate code based on the completed notes.

3. Lack of physician engagement and the decision to not seek training in ICD-10 documentation lends itself to inconsistencies of code assignments from one healthcare provider to another. Many EHR products carry over the diagnosed conditions in the patient's current and past medical history. Other providers from the same practice may choose to assign these same ICD-10 codes previously noted in the record. Even if the providers were to decide to assign their own code and not carry over the previous ones, the lack of uniformity in the practice not only implies that there are coding errors being made, but that the data collected by insurance carriers, independent research groups, government agencies, and public health organizations is not a valid representation of current illnesses. Additionally, incorrect data exchanged across electronic systems is useless information and potentially harmful to the patient's health when shared with outside healthcare providers and facilities involved in the care of the same patient. The movement toward ICD-10 was fueled by a critical need to improve the quality and effectiveness of patient care. Inconsistent and inaccurate data quality thwarts this purpose.

4. General Equivalent Mapping (GEMs) resources are intended to provide the most approximate equivalent code from ICD-9, cross-walked to each possible ICD-10 code. The translation is not a perfect one because ICD-10 includes a plethora of information that previously had not been part of the ICD-9 code description. For example, ICD-10-CM introduces combination codes that detail the underlying disease and current manifestation, routinely seen in diabetes affecting other organ systems. The new coding system has established several new concepts and features for

ICD-10 diagnostic codes, allowing providers to:

• Include information on laterality

• Identify if it is the patient's initial encounter

• Identify the gestational trimester in which the disease process was diagnosed (including the severity of illness)

• Include the external cause

• Expand on the description of injuries, fractures, complications, adverse effects, and poisonings to now include very particular information, such as:

– The Gustilo grade of an open fracture

– If underdosing or noncompliance is due to medication cost-reduction

– If the provider is treating a pregnant patient for a particular condition that first developed during the mentioned trimester and not the episode of care that she presented for

– If the resulting complication resulted intraoperatively or postoperatively

While GEMs serve as a time-saving tool, the matching ratio from ICD-9 to ICD-10 is most frequently not a perfect 1:1 correlation. Most ICD-9 codes will map out to multiple possible options for correct ICD-10 code selection. Exclusive reliance on the GEMs will lead to incorrect code submission on billing claims.

REVENUE DELAYS AND REIMBURSEMENT REDUCTIONS

1. The medical profession continues to be reimbursed on our current fee-for-service (FFS) system. National and Local Coverage Determination policies issued by CMS list and detail the diagnostic codes for symptoms and conditions that necessitate commonly performed diagnostic or therapeutic procedures. These acceptable diagnostic codes support the ordering or performing of any diagnostic tests or treatments. Incorrect ICD-10-CM assignment increases the number of "medical necessity" denials for CPT and HCPCS II procedures billed by physician practices.

2. CMS released data on healthcare providers, clearinghouses, and billing companies that participated in their July 2015 end-to-end testing with MACs and DMEs. Medicare published information stating 29,286 claims were received, but only 25,646 were accepted. Additionally, 52.7 percent of all submitted claims were professional services from healthcare providers, 2.6 percent of claims denied by CMS were due to submission of invalid ICD-9-CM codes, and 1.8 percent were due to invalid ICD-10 codes. This 4.4 percent denial rate was higher than the 3 percent reported in April's end-to-end denials. Health information managers (HIM) and providers spent 36 years learning how to assign three-digit to five-digit codes for a complete code selection. Now, providers and coders have to correctly select the required number of alphanumeric characters — anywhere from three characters to seven characters. Denials for invalid code submission further delay provider reimbursement.

4. The nearly quintuple growth in available diagnostic codes presents challenges when physician practices redesign their encounter form or superbill. Practices have to be selective about which commonly used diagnostic codes will be featured on the superbill for quick reference and which will be excluded.

5. Medical coders increase the number of queries addressed to healthcare providers for incomplete documentation and unspecified diagnostic conditions. While this is most likely to occur in the inpatient setting, physician practices with in-house medical coders will have billing claims held until the providers adequately respond to clarification requests.

6. Productivity rates decrease because of the increased time required to document properly for specific codes. Medical coders and HIM professionals take additional time to accurately locate and sequence the appropriate codes based on documentation. The increase delay in billing the professional claims increase the number of days in A/R and adversely affect the practice's cash flow. Independent providers and provider practices had been advised to budget for the anticipated financial impact at least six months prior to implementation.

EFFECTIVE MANAGEMENT AFTER OCT. 1

Several measures should be taken in order to streamline the transition in medical practices. Examination and revision of internal policies and processes is essential to ensuring that quality patient data is captured, while maintaining compliance in billing practices.

1. Provider practices should seek assistance from the EHR vendor.

• Vendors are best equipped to provide training and can also instruct office managers on how to run reports detailing the 50 most commonly used diagnostic and symptom codes in the practice.

• EHR companies can effectively re-label many diagnostic codes so that the keyword or main term appears as the clinician deems natural, and not necessarily as the medical coder is trained to look them up in the alphabetic index of the code book.

• The American Hospital Association (AHA) publishes quarterly guidance on ICD-9-CM and now ICD-10 code assignment. Many challenging coding questions have been posed to the AHA by medical coders and the responses are available and organized by ICD-9 and ICD-10 codes.

• CMS has publicly released physician guidance on ICD-10-CM coding in multiple medical specialties. Information tips are available to registrants of their listserv. Also, the "Road to 10" online resources are specifically designed to assist physician practices in raising awareness and promoting physician engagement, as well as offering free training for physicians and other healthcare providers.

• The National Center for Health Statistics (NCHS), an agency under the Centers for Disease Control, has additional resources. NCHS offers official guidelines on proper ICD-10-CM and ICD-10-PCS code assignment.

• The ICD-10-CM/PCS Transition Workgroup is an online community forum hosted and managed by the NCHS (on phConnect Collaboration for Public Health) to assist physicians in this implementation (visit bit.ly/PHC-ICD10 for more information).

• The American Health Information Management Association (AHIMA) offers a number of physician coding resources, including an "ICD-10 Toolkit" developed in 2012 which still proves relevant and instrumental today (visit bit.ly/AHIMA-ICD10-toolkit for more information).

• The AMA has printed and electronic ICD-10 publications on coding and documentation intended for providers. They offer online and live training for physicians.

Practices will need training and retraining after reevaluating post-implementation operations. Staff members come and go and providers may take medical posts in other organizations. Consistent and high-quality data reporting is essential and will directly impact practices as our healthcare industry phases out the FFS model and moves toward a value-based payment model. Practices should be making provisions for educational reinforcement after ICD-10 implementation, and should strongly consider the benefits of employing certified medical coders and HIM professionals.

BEST PRACTICES

The financial health of physician outpatient practices is affected by accurate ICD-10 coding. Just as importantly, patient health outcomes are directly tied to proper coding. Proper planning is key to compliance and optimal revenue management.

Continuing education and employment of certified coders will minimize coding errors. Close monitoring of the revenue cycle and reassessment of internal processes will help identify gaps. Utilizing industry resources is a cost-effective means of improving processes. All of these combined are ingredients in the best recipe for post-implementation success.

EHR and practice management (PM) systems come with built-in reporting capabilities but digesting all that information can be overwhelming. However, leveraging the power of Excel to sort and manipulate the data stored in your EHR can help you spot trends faster and implement steps to drive revenue growth.

“Excel is a great way to slice and dice your practice management data so you can really use it to improve,” says Nate Moore, CPA, MBA, an independent consultant and coauthor of “Better Data, Better Decisions: Using Intelligence in the Medical Practice.” “Excel allows you to filter, trend, and get your arms around reams of data.”

Excel offers an interactive tool called pivot tables that allow users to quickly sort, filter, and manipulate data, says Moore, who moderates the Excel Users Medical Group Management Association Community, an online resource for practice administrators. It gives users much more flexibility than an EHR, which typically offers a limited number of canned reports.

For example, your PM system can probably produce a general report on your collection rates at the front desk at the point of service. But a pivot table would allow you to slice that data in a variety of ways, such as individual employees’ collection rates by location or time of day.

In addition, you can connect Excel to the server where your data is stored so you are always working with the most current numbers, says Moore. That allows you to quickly run the same types of reports with updated data.

“A lot of practice administrators don’t run reports as often as they’d like because they take so much time to run and analyze using the PM and EHR,” says Moore. “Using Excel streamlines the process, making it more likely that reports will actually get produced.”

Moore offered a few examples of how pivot tables might be used to dig deeper into financial reports and zero in on potential problems:

1. Focus on overdue accounts. A general report on aging accounts receivable from your PM system might contain hundreds of pages, making it difficult to focus on specific trends. Exporting that data into pivot tables allows you to zero in on problem areas, such as claims overdue by 60 days categorized by insurer.

2. Gage productivity. If your compensation system is based on productivity, you can look at work relative value units by individual providers or during certain time periods.

3. Monitor workflow. Larger practices can monitor and compare activity at different locations. For example, how many patients did one employee register at a specific location vs. another employee at a different office? How many appeals or claims did each individual employee process at each office?

4. Analyze your patient base. Using a basic pivot table, you can see all of your new patients in a given year categorized by month of visit, referring physician, diagnosis code, insurance, or clinic location. Analyzing the data reveals trends, such as how many patients each physician saw in each year over the past five years.

5. Group data. You can group data to spot referral trends. For example, how many commercially insured patients did one group of referring physicians refer to each individual provider in your practice, for each of the past five years?

Several weeks following the implementation of the ICD-10 code set, the progress of the transition appears to vary according to size of the practice. While many large practices are reporting success with the transition, some smaller ones are reporting difficulty.

According to a blog post by the Coalition for ICD-10, many of the group’s members -- which happen to be larger healthcare providers -- are reporting great success with the transition. Many, like Centegra Health System, credit this success to the ample time for preparation they received.

“Centegra Health System was prepared for a smooth ICD-10 transition after two years of careful planning. Our information technology systems have been updated and our educational plans were deployed to help with the initial roll-out,” said Centegra’s Executive Vice President, Chief Financial Officer, and Chief Information Officer David Tomlinson.

Additionally, some coalition members stated that their success on October 1st is due in large part to their early implementation of the code set.

“Northwest Community Healthcare’s transition to ICD-10 has been smooth. This is due, in part, to our early clinical rollout of ICD-10 with our Epic Go-Live date of May 1, 2015,” said President and Chief Executive Officer of Northwest Community Healthcare Stephen Scogna.

Other members of the coalition, such as insurer Blue Cross Blue Shield of Michigan, reported a few bumps in the road amidst a generally smooth transition.

““BCBSM’s ICD-10 implementation went very smoothly. Call center volumes and overall inquiries are very low. Professional and facility claims are processing as expected. A few issues noted, which we are resolving, but nothing major to report,” the insurer said.

BCBSM also reported that it was the first private insurer to reimburse the hospitals it serves.

“Received kudos from our hospitals stating that BCBSM was the first payer to pay ICD-10 claims and these claims are paying as expected. Hospitals are not reporting any major issues. Other Payers (Priority, Cigna, Aetna) are reporting the same experience in that they are not seeing any major issues.”

However, this success is in contrast to what some other smaller providers are reporting. The impact of ICD-10 on smaller providers is a little bit more weary as these providers have fewer resources to work with.

For example, Linda Girgis, MD, FAAFP, told EHRIntelligence.com that due to how small her practice is -- she and her husband are the only physicians in the family practice -- its workload has grown much larger. This work includes changing patient problem lists from ICD-9 codes to ICD-10.

"The doctors are doing it right now," she says. "I'm doing it as I come across different patients, but definitely it's adding time on to the workday."

Smaller practices are especially affected by ICD-10 troubles because much of their revenue comes from the Centers for Medicare & Medicaid Services (CMS), and the agency has been reportedly unreachable throughout the transition.

"My biller tries to call every day. Since October 1, they have messaged that they are down due to technical difficulties so it's impossible to get through to any person there,” Girgis said.

Not receiving CMS payment is problematic for small practices like Girgis’ because those payments may amount to almost 30 percent of hospital revenue. While a larger hospital, like those mentioned above, may be able to do without 30 percent of its revenue for a month or two, this kind of issue could be potentially detrimental for a practice like Girgis’.

"Big organizations, hospitals, and groups can go a few months without 30 percent of their reimbursement coming in. But for small practices, that can be devastating," argues Girgis.

CMS set a timeline for rolling out ICD-10 payments, stating that those claims would be reimbursed within the first 30 days of the new code set. As that 30-day timeline draws to a close, small practices will be waiting to see if their claims are reimbursed.

EHR interoperability has been brought to the forefront lately as various health organizations and government agencies push for nationwide health information exchange. Furthermore, as integrated healthcare and care coordination become fixtures in the healthcare delivery industry, interoperability of systems between different kinds of practitioners shows itself to be critical.

A recent study by Maribel Cifuentes, RN, BSN, Melinda Davis, PhD, Doug Fernald, MA, Rose Gunn, MA, Perry Dickinson, MD, and Deborah J. Cohen, PhD, discussed how EHRs operated in 11 practices that were integrating the delivery of primary and behavioral healthcare. The researchers found that when behavioral health and primary care begins to integrate, the two kinds of practitioners brought separate EHR systems with them. This caused challenges and subsequent workarounds and solutions associated with EHR interoperability.

The study took 11 integrated practices in the Colorado area and gathered data regarding how EHRs worked for their needs, the challenges practices faced, what kinds of workaround strategies practices developed, and what kinds of long-term solutions the practices identified in order to promote care coordination over an EHR.

One of the challenges many of the integrated practices faced was that the EHRs were not necessarily designed to collect a certain kind of data. For example, in a primary care facility that hired several behavioral health counselors (BHCs), the facility’s EHR may not have been conducive to collective behavioral health data.

Third, many EHRs were not interoperable with each other, hindering primary care physicians and BHCs from working together in delivering coordinated care. The EHRs were also not compatible with tablet devices that were used to collect behavior health information in the waiting room prior to appointments. These tablets were used to present questionnaires that would provide behavioral health data. However, the lack of interoperability between these devices and EHRs made it so the data collected in the questionnaire could not easily be uploaded into the EHR.

The study reports four workarounds that were developed in the face of these challenges. First, as stated above, when the primary care and behavioral health practices first integrated, the physicians often had their own separate EHR systems. In order to make sure both systems had patient information, physicians had to manually enter the data into both EHRs. While this method may have been effective in ensuring patient information was stored in both EHRs, it was not particularly time or financially effective.

Second, medical assistants had to manually scan printed documents into EHRs. While this method may have also been effective, it presented several time and financial issues. Furthermore, the scanned documents were often harder to find in the EHR, hindering the physician from delivering care to patients in a timely manner.

Third, practitioners relied on patients and other physicians to recall patient information. This workaround was not effective because patient and physician memory was neither reliable nor accurate. One physician reported having to recall patient information that was told to him several weeks before meeting with the patient. Due to the amount of time that had passed since he had last discussed this patient, he was unable to determine what kinds of services the patient needed. This resulted in the patient taking tests that had already been administered.

Fourth, practitioners employed “freestanding tracking systems,” such as spreadsheets, that were not a part of the EHR. For example, one practice stored information regarding adolescents taking selective serotonin reuptake inhibitor medications in an Excel spreadsheet. Although this was widely used amongst the practice, it took enormous effort from practitioners to maintain, and the information on the spreadsheet was not easily integrated into the EHR.

By the end of the study, researchers observed that practices began moving past workarounds and toward more long-term solutions to their challenges in order to make their integrated practices more sustainable in the future. The researchers noted that these solutions were created by each practice’s own HIT teams and required their own funding. Three key solutions amongst the participating practices emerged.

First, many practices created their own customized EHR templates. These templates existed within their pre-existing EHR systems, and simply added more fields for data entry that would be more suitable for practitioners’ needs. However, developing these templates was an arduous task.

“Creating customized EHR templates was time consuming and required dedicated HIT staff working collaboratively with BHCs and primary care providers,” the researchers reported. “Practices that did not have access to these resources were not able to create customized templates as readily, or had to pay EHR vendors to do so.”

Second, some practices purchased EHR upgrades and reported several improvements from doing so, including increased interoperability, enhanced reporting templates, and more interfaces for integrating primary and behavioral health care.

However, EHR upgrades were considerable financial investments for practices. Practices were not allowed to upgrade their EHRs using the money allocated to them by participating in the study, so the upgrade needed to be a part of the individual practice’s investments. This financial burden made it so only five of the 11 participating practices were able to upgrade their EHRs.

The final emerging solution was the union of two EHRs. At the start of the study, four of the 11 participating practices were using two different EHRs -- one for behavioral health care and one for primary care. By the end of the practice, three of them were in the midst of merging those two EHRs, and one had built an interface that extracted data from multiple EHRs and stored the data in one place. While these solutions were quite complicated and costly, they were the most effective in overcoming interoperability challenges.

Despite the advances these practices made, the researchers maintained that integrated providers may still face hurdles in the future.

“EHR systems are not yet optimally designed to meet the needs of practices integrating behavioral health and primary care,” the researchers stated. “Our study found that EHRs generally lack features essential to support key integration functions such as documenting and tracking longitudinal data, working from shared care plans, and template-driven documentation for common behavioral health conditions such as depression.”

The researchers provided guidance on how to improve EHR use in integrated care situations, stating that perhaps systems need to start being designed for integrated care, as should different incentive programs.

“In the future, HIT systems should be intentionally designed, in cooperation with clinicians; to support and enable these integrated care functions, as well as the different modes of communication and care coordination tasks that occur between multi-professional members of integrated teams,” the researchers maintained.

Furthermore, the researchers stated that more financial incentives should be provided to allow practices to make these kinds of changes. Although several EHR and interoperability incentive programs exist, none of them provide incentives that would help practices change their EHR systems to make it more usable in an integrated practice.

EHR use presents many healthcare benefits, including coordination of care and increased patient engagement. However, , the lack of EHR and health IT interoperability is posing a serious threat to other healthcare initiatives, according to a recent report published by the American Hospital Association.

The report, entitled Why Interoperability Matters, discusses the various aspects of the healthcare industry and care delivery that are negatively impacted by a lack of interoperability. Among those aspects include care coordination, patient engagement, and public health and quality measures reporting.

Care coordination

The exchange of health information is critical for the coordination of care, according to AHA. When patients receive care from multiple different providers, physicians should be able to securely send relevant patient information to the practicing physician. However, that tends not to be the case because EHR systems are not interoperable and cannot exchange information.

Furthermore, care coordination and successful interoperability are vital for provider finances. As accountable care organizations and bundled payments continue to grow more prevalent, the AHA maintains that interoperability and the ability to see all of the care a patient in receiving is crucial in preventing unnecessary treatment.

Patient Engagement

Patient engagement and the shared decision-making between providers and patients is critical in achieving the aims of the healthcare industry, the authors of AHA report maintain. Further, patient engagement is a central part of federal regulations on using an EHR. However, the agency states that many patients are unable to access their electronic health information, hindering the practice of patient engagement.

“The real problem is that the vast majority of patients cannot access their health information in a holistic, meaningful way. Instead, they must go to each of their providers’ patient portals and download unintegrated data. Making sense of this, particularly for patients with multiple chronic conditions who frequently have many health encounters a year, is difficult,” the report states.

Public Health and Quality Measures Reporting

EHR use also provides the opportunity for enhanced public health reporting. Because patient data is aggregated on one, electronic system, healthcare professionals can track healthcare trends and analyze information about population health. But without adequately interoperable systems, that process is significantly hampered.

“Hospitals are happy to report this data to improve public health but must contend with a wide variety of reporting formats and transmission technologies to do so, including faxing, mailing, e-mailing, web forms and secure file transfer protocols,” report reads.

Healthcare providers have created a few solutions to this interoperability problem, including interfaces and health information exchanges.

Interfaces are programs that allow a facility’s EHR to pass along information from one system to another, yet practices face challenges when using interfaces for more than one provider.

“...in health care, each interface currently is like a snowflake: it must be built to meet the unique requirements between two providers and cannot be reused,” the authors explain.

Because practices would need to adopt multiple interfaces, they are not always a financially stable solution to interoperability.

Like interfaces, health information exchanges (HIEs) have presented themselves as potential solutions to interoperability problems. Although HIEs can be successful in securely transmitting health information between providers, they too are quite costly. Furthermore, AHA explains that many HIEs are installed via federal grants, and that when the grants run out, many practices are unable to maintain their HIEs.

Health IT standards need more specificity

Although there are a set of standards identified for the use of EHRs and other health IT, they are not specific enough to be effective, the authors note. Creating uniformity in how data is collected and stored on an EHR, however, would be a drastic step forward for interoperability, the report states. Increased health IT standards would cause data to be input in the same way across the healthcare delivery spectrum, making information sharing more feasible.

Although the authors acknowledges the potential that health IT standards have in increasing interoperability, the agency maintains that much work in defining those standards and developing other platforms needs to be done before the industry can achieve nationwide interoperability.

Throughout my HIM career, I have seen many different methods of capturing clinical documentation. We are always looking for solutions to get accurate and complete clinical documentation into the medical record in a timely manner with minimal disruption to the provision of care. The processes for gathering documentation have evolved with advances in technology and HIM professionals have been very involved in ensuring the quality of the documentation.

When I first began working in an HIM department, we had a Transcription department with hospital-employed transcriptionists and a management team devoted to medical transcription. Quality reviews were performed regularly and the transcriptionists had an ongoing relationship with the physicians to provide feedback and get clarifications. As part of this department, there were file clerks in charge of filing the transcribed documents onto the paper medical records throughout the day and into the night. When I think back on these practices, it seems like an entirely different lifetime from today’s practices yet it really wasn’t that long ago.

Over time, transcriptionists began to disappear from hospitals as the task became outsourced. Vendors have offered to do the job for less cost and they guaranteed a high quality rating of the transcribed reports. However, transcribed reports often still come back to the medical record with blanks and anomalies that must be corrected by the dictating clinician which can delay the documentation reaching the chart. It’s important to review documents to make sure there are no obvious errors that may have been misinterpreted by the transcriptionist or the back-end speech recognition system.

Many are still relying on outsourced transcription as a major source of capturing documentation but this is evolving as EHRs have created new opportunities for documentation. EHRs provide documentation tools such as templates to import data into the notes and allow for partial dictation for the narrative description. The negative side of this is that copy and paste is used frequently due to the ease of grabbing documentation from the rest of the EHR and pasting it into the note to save time. Clinicians using copy and paste may not realize that the information could be outdated or it could be against company policies. This now requires quality reviews to monitor the use of copy and paste and the relevance of the documentation to maintain the integrity of the medical record. This should be incorporated into chart audits or other quality review processes.

Front-end speech recognition tools are popping up frequently as an additional tool to capture documentation. A concern with this is the shift from having quality reviews performed by the transcriptionist to now relying on the clinicians to edit their documentation as they dictate. Many are creating positions in HIM departments to perform quality reviews on the documentation to not only ensure the documentation is in the record in the adequate timeframe but making sure the documentation is accurate for each patient. It will be interesting to see how clinical documentation continues to evolve as new methods of capturing documentation are developed and deployed. No matter how the information gets into the medical record, HIM professionals still have the ultimate responsibility to ensure the quality of the documentation for patient care and appropriate reimbursement.

Larger EHR vendors tend to make better partners in achieving Stage 2 Meaningful Use, according to a recent study by Peer60. The study, which discusses insights and trends in EHR vendors, sought to identify the which vendors play a bigger and more supportive role in providers’ work to achieve meaningful use.

According to the report, users of notable vendors such as Epic, Cerner, and Allscripts stated that these technology partners delivered adequate support for their efforts to meet meaningful use. Among these vendors, many users also reported being in the midst of attesting to Stage 2. Epic also had several respondents report that it was not an adequate partner in Stage 2 attestation, but given the high volume of users Epic engages with, the positive reviews significantly outweigh the negative.

Other vendors did not receive such favorable reviews, according to Peer60. Among those is McKesson, who received nearly double the percentage of negative reviews as positive ones. McKesson also has a substantial number of users who report still being in the process of attesting Stage 2. A few smaller vendors also received negative meaningful use reporting reviews, including NextGen and Practice Partners (which is owned by McKesson).

Of the practices surveyed, nearly 90 percent of them have either achieved Stage 2 or are in the middle of attestation. Fifty-six percent of respondents had successfully completed Stage 2 attestation, and 34 percent were in the thick of attesting. Only 10 percent had not successfully attested, and Peer60 reports that about half of those who had not been successful “simply don’t have the proper model to receive enough benefits to bother attesting.”

This report comes out after CMS released data regarding meaningful use registration and participation. Given that data, it appeared as though the delay in the release of the meaningful use modificationrules was hindering program growth. According to CMS, meaningful use enrollment stayed stagnant between the months of May and August. Medicare eligible professional (EP) enrollment also remained relatively the same between May and July, and skyrocketed in August. Likewise, eligible hospital (EH) enrollment stayed consistent between May and July and made a notable jump in August.

Now that the Stage 2 Meaningful Use Modifications Rule has been released, the rate of EHR Incentive Program enrollment may increase. Because the modified rule eliminates unnecessary and cumbersome requirements, as well as shortens the initial reporting period to 90 days, it is expected that more providers will enroll in the program and will be able to achieve success.

However, success could potentially be better facilitated by an EHR vendor that is more supportive and provides a product that works better with meaningful use. As such, EHR vendors may need to adjust their practices in helping providers meet meaningful use guidelines in order to remain competitive in the EHR market.

At a time when American providers are offering some of the best care in the world, even the smallest medical practices cannot slip. They must offer top-tier services, while meeting and maintaining compliance with government regulations. This is no small order, and it's made increasingly difficult considering the price tag that comes with integrating cutting-edge technology — in particular, EHRs — into an office, especially for solo practitioners or practices with just a handful of doctors.

While the incentive to invest is greater than ever with the ongoing meaningful use program, the cost of implementation is still pricey. Physicians working in the smallest practices have to get creative when trimming technology expenses.

KEEPING COSTS IN CHECK

"Maintaining an electronic health record system is our largest expense," says pediatrician R. Frerichs of North Raleigh Pediatric Group. His practice isn't an isolated case. According to a survey in Medical Economics from February 2014, 45 percent of physicians spent more than $100,000 on EHR systems including service, hardware, software, training, and consulting. However, there are ways to shrink that number considerably.

It is easy to feel overwhelmed by options available in the marketplace. Practices on the hunt for tech investments must be mindful of what is specifically needed. "There is a want to measure everything without knowing why or what to do with the measurements," says Kyle Wailes, senior vice president of physician services at the Ft. Lauderdale, Fla.-based technology solutions provider, Intermedix. "A smart and focused practice can avoid much of this by determining must-haves ahead of time and knowing exactly what is needed when purchasing technology."

In addition to searching for the product that best matches a practice's needs and work flow, there is value in adopting open source products. Dozens of open source software programs have been developed for the medical industry with data security and usability at the forefront, says Greg Scott, owner and operator of Infrasupport Corporation, an IT consulting firm in Eagan, Minn. With open source software, physicians don't have to become IT experts, since someone else developed the software and the additional features. They do have to be willing to explore technology built using an open source model by accepting patches, new features, and other support built by an interested community. Any potential inconvenience is likely to be offset with the cost savings, which can be as much as 80 percent compared to proprietary competition, Scott says.

Similarly, practices should seek out "disruptive vendors" — those working on the innovative edge of mainstream technology — because they typically have lower gross margins, smaller target markets, and simpler products, experts say. Though the products and services may not appear as attractive as existing solutions when compared against traditional companies, the cost is often cheaper, says Austin Kirkland, principal and founder of healthcare management services consultancy Outperform, LLC, based in Falls Church, Va. "Many businesses have developed software tailored to suit specific specialties or to operate with less robust features, lower development costs, and reduced operating overhead," he says. "As a result, they are able to offer their products at a better price point to specific buyers than their larger competitors, so shopping for the right solution can save money."

Once practices have made the initial investment for EHR and practice management systems, there are ways to manage the ongoing costs associated with overseeing them. The unfortunate truth is that technology requires constant upgrading to remain efficient and compliant, which of course, comes at a cost. Instead of hosting technology infrastructure onsite at a practice, medical offices should consider migrating most (if not all) technology services to a cloud services provider or third-party data center. Doing so requires an initial upfront cost, but service fees are generally paid monthly at a predictable, scalable rate. Additionally, this frees medical practices from worrying about hardware failures or updating software because managing those responsibilities falls to a third-party vendor.

SHRINKING PAYMENTS IN A SMALL PRACTICE

Despite doing due diligence to select the best and most cost-effective products and maintenance options for a small practice, the fact is that someone still has to pay the bill for technology.

One of the best things practices can do is find support within a larger group of physicians. Frerichs says his participation in a practice management group called Raleigh Durham Medical Group (RDMG) has been a critical factor in his ability to manage costs for his practice. "The power in numbers allows us to negotiate deals for pricing that I would not be able to attain alone," he says. For example, he adds, collaboration through RDMG allowed them to obtain optimal pricing for purchasing an EHR. Furthermore, when the need to replace or update equipment arises, the group provides flexible financing options.

Flexible financing also allows physicians to relieve some of the weight that comes with buying technology outright. For practices that don't have credit available to take term loans — or those that simply choose not to — leasing options are available. This ensures practices have cash on hand to pay for consumables, payroll, fees and taxes, and other necessities, says Jim Phelps, CEO of Beaverton, Ore.-based equipment financier, Capital Equipment Leasing, and it keeps a line of credit open for other needs. Leasing also removes the permanence that comes with an outright product purchase, allowing companies to upgrade or change technology with minimal cost. "Software and hardware can be leased on a turn-key basis, allowing the practice flexibility as needed to move at the end of a lease and to avoid upfront capital needs," Kirkland says.

Though hardware and software can be leased, other products can as well. Phelps' company has leased digital X-ray, sonogram, and MRI machines, and exam tables. "We can lease any equipment that is not 'body invasive,'" he says.

Investing in technology, whether hardware and software, diagnostic equipment, or other necessary products and services, is a given in the medical industry. Small practices must be innovative to keep on top of advances in the industry, because the ultimate bottom line is providing the very best care to each and every patient.

Is it time to go a new route with your EHR system? Before you decide yes or no, weigh the positives and negatives.

Only 34 percent of physicians are satisfied or very satisfied with their EHR systems, according to a recent survey conducted by the American Medical Association and AmericanEHR Partners. Another survey published in the American Academy of Family Physicians' journal, Family Practice Management reported that only 39 percent of respondents who changed EHRs were pleased with their new system.

The results of these surveys outline how the decision to change EHR systems or not is a difficult one. After all, it's a significant financial investment and staff have spent a lot of time learning how to implement and use their system. If you change, your practice will have to foot these costs all over again. In addition, you face the potential loss of data and problems with data migration.

HANG IN THERE

"A well-designed EHR should be physician centric, specialty specific, and serve as a tool for the physician to document a patient's visit," says John Pitsikoulis, managing director of Berkeley Research Group, LLC, a firm located in Hunt Valley, Md. "The EHR must also meet the practice's business needs, including the revenue cycle. When an EHR doesn't align with a practice's specific day-to-day work flows, it makes the physician's job more difficult by increasing [his] administrative and compliance workload. By negatively impacting the physicians' time, patient care is impacted."

While it's tempting to want to replace something that doesn't meet your expectations, under certain circumstances you may want to give it more time. "First, determine if your current system offers enough functionality for managing your practice and achieves meaningful use requirements set forth by CMS. Also, verify that the vendor's strategy for future enhancements outweigh any short-term disadvantages," Pitsikoulis advises.

If your practice likes some of the core features and functions of the system, already developed specialty-specific templates, and can live with navigating through notes, orders, and prescribing without overwhelming frustration, living with the current system makes sense at least for the short term, Pitsikoulis continues.

One common complaint of physicians is that they have become data entry clerks at the expense of patient care. "This is a common physician finding, regardless of the EHR system," Pitsikoulis says. "But changing systems could result in the same functionality."

The truth of the matter is that a lot of systems aren't lacking in functionality and can be beneficial if you take the time to learn how to use them, says Eagan, Minn.-based Derek Kosiorek, principal consultant of Medical Group Management Association (MGMA) Healthcare Consulting Group. One way to determine if this is the case at your practice is by finding out which physicians successfully use the EHR. If it's more than half, then the EHR isn't the problem and other doctors need to invest more time in learning to use the system more efficiently. See if those doctors can assist others in learning the system.

TROUBLESHOOTING

Before throwing in the towel, see if the vendor is willing to work with you on resolving issues. Work with the vendor to identify each problem and then ask if the vendor can offer a solution, says Mechanicsburg, Pa.-based David J. Zetter, founder and consultant at Zetter HealthCare.

If it is more difficult to order tests or enter information into the medical record than before having the EHR, something is wrong, says Ann Arbor, Mich.-based Joette Derricks, owner of Derricks Consulting, LLC. The EHR should streamline the work flow, not add more steps. If employees are printing out information and still depending on paper, something is probably not set up properly. Open communication is critical to identify and resolve problems.

Making some enhancements to the EHR documenting process with voice recognition software, streamlining the physician coding function with built-in coding software, and optimizing the EHR features and functions with templates, could provide some shortcuts that make an EHR more desirable, Pitsikoulis says.

However, be cautious when adding these enhancements. Engage consultants with operational, technical, and coding compliance expertise to integrate the physician's work flow with the technology. "Otherwise, you might end up with similar performance dissatisfaction with the next tool," Pitsikoulis says.

PULL THE PLUG

Sometimes, despite your best efforts, you may want to call it quits. Poor technical support is a key reason to get a new vendor. "Oftentimes, marketing staff is very accessible early on and then a year after implementation you can't get a basic question answered," Derricks says. In this instance, it's time to move on.

Furthermore, if the vendor does not update its software to facilitate new medical technology or contractual payment updates, that's problematic, Derricks says.

In addition, if an EHR lacks the ability to integrate with other software such as laboratory tests, diagnostic tests, practice management systems, and so forth, it's probably time to start anew, adds Zetter. Other reasons to say "adios" are if staff cannot effectively use the system, if it impedes patient care, or if it's just too costly to continue to use.

Or, if information is consistently incorrect because the system is set up poorly, or you're finding bad data, start over, Kosiorek says.

MAKING A DECISION

Even though EHRs may pose a lot of challenges, their ability to exchange health information electronically has enormous benefits. EHR capabilities, such as electronic prescribing, improve patient and provider communication, while providing for the patient.

If you're unhappy with your EHR, it's important to understand what went wrong in your last EHR selection so you don't repeat those mistakes. Perform a needs assessment by categorizing the current deficiencies and determine if these can be improved. If not, then it's time to begin the process of selecting a better EHR.

CHOOSE RIGHT THE FIRST TIME

After incorporating a new EHR system, many physicians will have to change the way they've done their job since beginning their careers. "They are being asked to take information in their paper chart, shuffle it like a deck of cards, and then have it presented to them in various places on a computer screen," says Eagan, Minn.-based Derek Kosiorek, principal consultant of the Medical Group Management Association Healthcare Consulting Group. "Then, they have to get used to navigating to where the information is relocated. This can be difficult, as some vendors in the early days of creating EHR software didn't design it in the most user-friendly way for physicians."

Fortunately, this is evolving, but as a result it's leaving some physicians wondering whether to stick with the old or upgrade to something new.

Whether selecting an EHR for the first, second, or third time, the selection, implementation, and integration of work flow with new technology is complex, and requires continuous process improvement. "Usually, the need to make a decision and begin the implementation process gets in the way of a complete and thorough understanding of the technology and the practice's needs," says John Pitsikoulis, managing director of Berkeley Research Group, LLC.

When beginning the process of selecting an EHR, a practice's providers and staff should have an opportunity to "kick the tires." Yet, very few often do, says David J. Zetter, founder and consultant at Zetter HealthCare. Trying out a potential system gives users a chance to determine if it's a good fit. For example, they should ask the vendor "How will the EHR work with the practice's way of documenting a patient encounter? How will the practice management part of the software suite work? And, what is the reporting like?" And to make sure that the EHR will fit your unique needs, talk to other same-specialty practices that use the same system.

In addition, practices often fail to thoroughly check references. "Don't accept only a few names as references," Zetter says. "Ask proper questions of many practices that have implemented it, such as 'Would they choose it again? Why or why not?'"

When beginning an EHR replacement project, it is important to carefully consider your practice's true needs and intentions.

The health IT industry is changing, and an upsurge in EHR replacement makes that change clear. From ever-changing meaningful use requirements to varying practice needs, healthcare organizations find that their original EHR acquisition may not have been the best choice. Upon facing substantial EHR difficulties, these organizations seek to find a better replacement for their technology.

Changing EHR replacement trends can be credited to the ubiquitous adoption of the technology following the meaningful use program implementation and the changing landscape of the healthcare industry.

As more healthcare organizations are expected to replace their EHRs, it is important for them to understand best practices to keep them from having to undergo the same process years down the road. Below are some of the industry’s best advice for successful EHR replacement:

Be thoughtful and patient when determining practice needs

Organizations considering an EHR replacement do so because they have some considerable problem with their existing technology. Because of that, it might be easy for the hospital’s health IT leaders to quickly jump to what they think may be a cure-all solution to their problems.

Industry experts caution against this, explaining that IT leaders should be patient when developing an idea of what they specifically need in a new program. By taking the time to flesh out exactly the kinds of issues the practice has been dealing with, and exploring different options for fixing those issues, an IT team can better assess the direction in which they need to go.

Mark Hess of Stoltenberg Consulting Group, a company which guides practices through EHR replacements, says this has been his most successful practice in helping to facilitate an effective EHR replacement. Choosing a slower EHR replacement process is key to alleviating biases IT teams may have due to failures of old systems.

"Optimally, if we can get them down this road, we see the biases become diluted, they become more objective, and many times they'll come up with a very different decision than they would've had they gone the 90-day or quick-turn process," Hess told EHRIntelligence.com.

"By having corporate site visits, by having several rounds of demos, they come to a different way of thinking about how to make a decision,” Hess continued. “It's more global and enterprise-wide, more strategic in nature, less biased, and really what's best for the organization."

Foster physician buy-in, positive hospital culture

Once IT teams have chosen their new EHR software and taken time to determine new goals for using the software, it is important for them to foster physician buy-in.

Physician buy-in is crucial because if a physician doesn’t believe in the benefits the product promises to display, he won’t use the technology to its fullest potential. Physician resistance to EHR systems is one way that otherwise successful implementations fail.

IT teams and other organizations leaders need to remember that although their EHR system may be changing, it is their hospital culture that will make all of the difference. In a 2015

KLAS publicationImplementation Potholes 2015: How to Smooth Out the Ride, researchers explain that an EHR vendor can’t change practice culture; only leaders can.

One of the best ways to facilitate physician buy-in and promote good morale and positive workplace culture is to emphasize the patient safety benefits an EHR system will bring. IT leaders should also emphasize the long-term benefits of the system to negate the short-term difficulties providers are sure to face in replacement.

Showing executive commitment to the provider may also boost morale and facilitate positive culture. Providing ample help resources to providers when implementing an EHR was one way Avera McKennan CEO Dave Kapaska, MD, was able to see success.

“We tried to put as much help at the shoulder as we could so they weren’t left swimming at sea with the process,” Kapaska said. “[We] just committed ourselves both as on the administrative side but most of all on the physician side to get this to a point where it was functional and efficiently effective.”

Consider meaningful use changes

A new added foil to the EHR replacement issue is the impending change to meaningful use requirements.

Since the start of meaningful use, many providers have shaped their EHR adoption and replacement intentions around meaningful use requirements. However, since the Centers for Medicare & Medicaid Services (CMS’s) Andy Slavitt’s announcement that the meaningful use programs will essentially be broken down and restructured, providers will have new meaningful use concerns.

Per Slavitt’s announcement, the meaningful use programs will most likely focus more on provider needs to give quality care to the patient rather than abiding by sometimes arduous government requirements. Because of this, IT teams will need to take into account provider needs when selecting potential EHR replacements.

IT teams may have more EHR options going forward, too. Slavitt explained in his statement that one of the tenets of the future meaningful use is flexibilities for vendors to develop systems that cater to provider needs. This could make all of the difference when approaching EHR replacement.

Earlier this week, Andy Slavitt, Acting Administrator for CMS, told a group of attendees at the J.P. Morgan Annual Health Care Conference that meaningful use is on its way out.

“Now that we effectively have technology into virtually every place care is provided, we are now in the process of ending meaningful use and moving to a new regime culminating with the [Medicare Access and CHIP Reauthorization Act of 2015] (MACRA) implementation,” Slavitt told attendees. “The meaningful use program as it has existed, will now be effectively over and replaced with something better.”

The idea that meaningful use, a program which began in 2011 and aimed to incentivize or penalize physicians for adopting an EHR system, would be over, naturally caused many physicians to celebrate. Melissa Young, an endocrinologist in Freehold, N.J., and a member of the Physicians Practice Editorial Board, e-mailed a three word reaction to the news: “Hooray! ‘Nuff said.”

The AMA had a more formal way of celebrating this news. Of Slavitt, AMA President and CEO, Steven Stack, an emergency physician, told Beckers Hospitals Review in a statement: "He listened to working physicians who said the meaningful use program made them choose between following Byzantine technological requirements and spending more time with their patients. This is a win for patients, physicians and common sense."

In his speech, Slavitt talked about winning the “hearts and minds” of physicians back. Getting rid of meaningful use would undoubtedly help the federal agency achieve that goal, as evidenced by the rising number of docs who opted out of the program due to its stringent requirements. “The concept of meaningful use was always doomed to failure and it has been proven that there is no improvement in the quality of our healthcare delivery system and it has not reduced the costs of the provision of medical care,” Jeffrey Blank, a podiatric physician in Loxahatchee, Fla., and a member of the Physicians Practice Editorial Board, said via email.

Hold that Thought

Despite the excitement, Robert Tennant, health information technology policy director for the Medical Group Management Association (MGMA), says physicians should keep the champagne on ice. For one thing, they will still be judged on EHR and technical capability.

At the conference, Slavitt talked about MACRA, which authorized the creation of the Merit-Based Incentive Payment System (MIPS). MIPS will measure and compensate physicians on quality, practice improvement, cost, and use of technology. Within MIPS will be elements of meaningful use. Rather than rewarding physicians for using technology, MIPS will aim to pay them on using it towards improving their outcomes.

While Tennant says a reworked meaningful use is “potentially very positive,” the guidelines for MIPS are supposed to be released and finalized this year, which he notes could be a problem for physicians. “Payment under MIPS is supposed to take effect in 2019. If the traditional approach of using a two-year look back [to make those adjustments] is in place, it would mean reporting would begin in 2017,” he says. “If you look at the timing from a regulatory process, we’re concerned with how this would be accomplished.”

In essence, vendors would have to redevelop software around the guidelines, train customers, and practices would have to go live within the space of a year. Moreover, Tennant says if MIPS regulations are finalized in December of this year, they’d likely overlap with a new presidential administration.

“Any new administration, the first thing they do is typically put all pending regulations on hold and review them before they approve,” he says. Tennant also notes practices still have to be concerned over meaningful use regulations for 2016, including a full-year reporting period and the fact that Stage 3 of meaningful use is technically supposed to be mandatory in 2018.

“We don’t know what we are moving ahead to,” Tennant says. For practices, he advises to select software that fits their clinical needs and to not worry about “arbitrary and potentially changing” regulations. “Don’t focus on 2017 or beyond. We don’t know. The vendor doesn’t know.”

Even still, he is “cautiously optimistic” about Slavitt’s remarks. “We’re hoping CMS takes this opportunity to leverage MACRA to develop a program that is achievable and clinically relevant,” he says.

Blank is interested to see what lies ahead with government regulations, but is not as optimistic as Tennant. “I'm sure that many interest groups and the insurance industry will profit and doctors like me will continue to struggle,” he says.

I’ve been a very good doctor all year. I have checked all my boxes and aced all my Meaningful Use requirements. This year, I’m not asking you for anything fancy. I just thought you might be able to instill some kindness and good will into the people who designed the user interface of my EMR. Maybe, with your help, they would come to see how a few minor tweaks could make the practice of medicine safer and more efficient, and my day a lot more enjoyable than it already is:

1) I wish I could see a routine laboratory panel, like a CBC or a CMP, in one view without scrolling inside a miniature window. That would save time and help me not miss abnormal results.

2) I wish the patient’s next appointment date was displayed next to any incoming report I have to review. That would help me decide if I need to contact the patient about the results or if I’m seeing them soon enough that I can talk about the report then.

3) I wish I could split my computer screen so I could see an X-ray or consultation report or a hospital discharge summary at the same time as I type or dictate the narrative of my office note. That would help me quote them correctly.

4) I wish, when I open a patient’s actual visit note for today, the place where I do my documentation, that I could automatically see at least the beginning of the latest of every category of information we have received – latest labs, X-rays, outside reports and phone calls. It takes too much time to go searching in the places for each category separately just in case there might be something recent to catch up on in the visit.

5) I wish my EMR would know that prn medications, such as nitroglycerin, are not meant to be used for only a limited time, like 30 or 90 days, and would agree to e-prescribe them without a “duration”. If I could do that, they would not disappear from the medication list all the time.

6) I wish my EMR would automatically display the patient’s kidney function and allergies next to where I pick what medications to prescribe. That would make prescribing quicker and safer.

7) I wish my EMR wouldn’t alert me to drug warnings and interactions that are too obvious to need reminders for. I mean, any doctor would know that adding a second diabetes pill can cause low blood sugar (that’s why we do it) and that combining two drugs that can cause fatigue may cause even more fatigue! More intelligent warnings would be taken more seriously; now my trackball finger is automatically poised to close the “warning” pop-up, because I’m expecting it to be irrelevant.

I’m sure if I tried, I could think of an even ten wishes, or maybe even twelve – one for each day of Christmas. But these seven things illustrate the underlying, fundamental wish I have: that my EMR will evolve to be more user friendly. I wish, now that the basic functionalities of EMRs are in place, that somebody comes back to people like me and asks how to take this thing to the next level.

"Having accomplished the significant goals of greatly expanded EHR adoption and baseline interoperability via Direct, but also having alienated almost the entire health care provider community by overreaching for the final, Stage 3 version of its regulations, the Meaningful Use programs will be phased out by the end of 2016," the organization maintained in a public statement. "Providers are particularly worried because the requirements of Stage 3 MU do not align well with MIPS and MACRA, the new rules under which Medicare will pay for value and performance, rather than for volume of care."

DirectTrust sees things playing one of two ways.

"It may occur as a result of massive defections by providers willing to face fee schedule penalties rather than spend more resources on health IT that doesn’t add value to their practices and hospitals, it continued. "Or, it may happen as a result of Congressional action, or because CMS and ONC see the hand-writing on the wall and scale down and bow out gracefully."

The organization's prediction echoes the sentiments of Beth Israel Deaconess Medical Center CIO John D. Halamka, MD, MS, who less than a month ago asserted that meaningful use had served its purpose and ought to give way to Medicare Access and CHIP Reauthorization Act (MACRA).

Similarly, both DirectTrust and Halamka consider the lofty aims of Stage 3 Meaningful Use are sufficient cause for moving away from the federal program.

Elsewhere in its health IT predictions for 2016, DirectTrust expects patients to take on a more significant role in ensuring the electronic exchange of their health data:

Patients will have greater access to their clinical records, and they will be able to more freely and easily move those records whenever and to whomever they choose. Health care consumers will take as their right control of their own health information in much greater numbers. The corresponding willingness of provider organizations to permit this patient engagement — and to view it as positive and productive to attaining better health outcomes — will also become more evident across the U.S.

The consequence will be a freeing of data and an increased focus on patient-facing applications although it may not go as smoothly as desired.

"This will not happen linearly; rather it will grow explosively, and then suffer hiccups and setbacks as the privacy and security risks of such systems are first exposed, and then dealt with. But it is going to happen," the group added.

This is likely to tie in with another of its predictions — the coming to the fore of health data security and privacy in 2016.

"The cost of data breaches in health care is simply too high to be tolerated," DirectTrust stated. "As use of electronic health information exchange soars, we will experience a corresponding rise in concern about and actions taken to mitigate the risks of exposure of both data at rest and data in transit. Parties involved in electronic data exchanges will insist on more and more rigorous certification, accreditation, and audit of security and identity controls as a first condition of participating in data sharing."

In its remaining predictions, the organization anticipates a movement toward greater interoperability on the part of federal and state agencies as well as a growing reliance on Direct exchange for enabling the secure and interoperable movement of health data between and among providers for the purposes of care coordination.

Different EHR vendors perform better in various different countries, according to a new KLAS Global Performance Report.

Despite having distinct popularity and success throughout the United States, Epic Systems is not necessarily the top-performing EHR product throughout the globe, according to a recent KLAS report.

The KLAS Global Performance report breaks down user-perceptions of various different EHR systems by region, such as Asia/Oceania, Europe, Latin America, the Middle East, and North America. Results show that although Epic Systems receives high praise throughout the US, and also performs well in Europe, the vendor does not have a stronghold in other regions.

The the best vendor performances in multiple regions, in fact, belonged to Cerner and Intersystems with high performances in Europe, Asia, and the Middle East.

One of the significant barriers vendors face in implementing their systems abroad are state contracts which limit certain functionality. Several companies, such as Cerner and Intersystems, have trouble implementing in Australia due to contractual issues.

Cerner’s implementation in the UK serves as an example of EHR systems that can be successfully implemented provided full adoption and fewer contractual limitations.

Although Epic is not seeing solid performances or high adoption rates in all regions, it is seeing success at larger health systems in other countries. Of the seven international Epic users interviewed, all of them reported full adoption of the systems, and strong functionality and support.

Vendors that do not see success at larger health systems include Allscripts and Phillips. Allscripts users report complications with implementation and support, while Phillips states that it faces difficulty garnering larger users to adopt their systems.

Cerner has garnered the most success throughout Europe, with the most ubiquitous successful adoption throughout the entire continent. That said, Epic has nearly 100 percent approval ratings from European users, though they are almost entirely located in one nation (the Netherlands).

As previously stated, Cerner’s clients in Australia are having difficulty with implementation. This is because of the way in which user contracts are established. Reported issues include a need for increased functionality, more system training, and increased systems optimization.

Despite Epic’s inconsistent international ratings, the EHR vendor continues to prove successful in the US. Between Epic’s many users’ awards, as well as Epic’s own honors, the vendor maintains its foothold as a health IT giant.

Additionally, Epic won out in a recent Peer60 study of the physician-ranked most innovative EHR systems. Among the C-suite executives surveyed in the study, Epic won out as the overall best EHR system in operation. The vendor was also selected as one of the most intuitive and easy-to-use models on the market, and the top choice for CIOs.

Cerner and its users were also successful in the US this year, receiving KLAS’s best small ambulatory EHR award for 2014. Cerner also received two other KLAS awards in 2014.

In the aforementioned Peer60 study, Cerner was ranked as one of the most intuitive models on the market, as well as a top choice for COOs.

Perhaps most notably, Cerner was recently selected as the choice EHR for the Department of Defense EHR modernization project in partnership with Leidos Partnership for Defense Health. The partnership, which is currently valued at approximately $9 billion, was a significant feat for the EHR vendor.

“The Leidos Partnership for Defense Health is honored to have partnered with the Military Health System for nearly three decades, and we are committed to continuing our work in support of its mission to improve the health and medical readiness of our military,” Leidos representatives said in a public statement. “Our team stands ready to lean forward with the DoD to implement a world class electronic health records system.”

I love traveling for a variety of reasons. One of the biggest is the ability to meet a diverse group of people who start as strangers and become friends. On a recent trip to San Francisco, I had breakfast with an IT professional working in the banking industry. Our conversation turned to the proliferation of data in both of our worlds, and how it can complicate the analysis and productive use of that data.

I have worked as a PA for more than 34 years, and have witnessed a dramatic transition of how we collect and view patient health records, from paper records and manual charting to the modern EHR and computerized physician order entry (CPOE) systems.

In my travel buddy’s banking world, similar to the medical world, data management is an expensive proposition. The size and complexity of the data expands exponentially every year. Software is the interface between professionals in our fields, allowing us to interpret and record information into this burgeoning database.

It has dawned on me on more than one occasion that the weak link in this whole system is the end user, and this is true for every industry. I have observed over the years the age diversity of physicians, PAs and others providers directing patient care within the healthcare system in the U.S. Prior to computers and digital data, we all charted the same way. The only tool that we all had was pen and paper. This has changed dramatically over the past ten years.

A number of policy changes on the federal level, as well as the Affordable Care Act, have driven a rapid transition to the EHR at every level of the healthcare system. A combined carrot and stick economic stimulus has been the force behind this transition. It has, at times, been challenging from a provider standpoint. I imagine that it has been the same from the corporate level.

I can only address the view from the trenches. What used to be a uniform documentation system has moved into one in transition. We don't allow anything but CPOE in our hospital. However, we still allow handwritten progress notes. Administration has moved gently in this area in order to cater to some providers’ lack of computer skills. While everyone is different, having practiced healthcare for many years, technology adoption can fall into several transitive groups.

Today’s recent medical professionals are highly computer literate, and have never touched a paper record, and never will. They can research a patient problem, FaceTime with their friends, text, and handle e-mail all at the same time, from a variety of devices.

Then, there is a middle group who have grown up in the computer era and have decent computer skills. They remember the paper era, but see the promise of the digital age and are able to keep their heads above water in the burgeoning digital age.

The last cohort is my age group, those nearing retirement who have spent the majority of their careers in medicine in the paper age. Many in this age group find managing technology to be a frustrating endeavor. However, with challenges and transitions come opportunities and I have seen many baby boomers and hospitals adapt to leverage more holistic systems. It simply takes patience and a little bit of flexibility.

That said, we have to be gentle in our expectations of the transition towards a digital world. Big organizations, like the one running the hospital in which I work, have deployed many resources towards easing the transition towards the EHR that are available 24/7.

Unfortunately, some providers in private practice might not be so lucky, and find themselves having to go it alone. Assisting all those at every level of EHR skill and ability is imperative toward full implementation of the EHR.

Patience is an important virtue in this transition. Nothing this difficult and complex can be done easily or quickly. However, by being reasonable and rational about the problem that we are trying to solve — being flexible and ensuring we are building tools that will ultimately allow us to better serve our patients — will help with the solutions towards dealing with the mountain of data that is burying every industry in the nation, service or otherwise.

Adhering to patient safety standards is of vital importance when using an EHR, which is why proper review and research among different systems are critical for innovation. However, are supposed gag clauses in EHR vendor contracts inhibiting this kind of review and research?

A recent Politico article written by Darius Tahir presents considerable research into the matter. According to Tahir, EHR users are being completely prohibited from sharing adverse events and negative feedback regarding their EHRs. This stems from different gag clauses included in EHR vendor contracts, and seriously affects innovation that can help improve patient safety.

But HealthAffairsarticle by Kathy Kenyon, JD, MA, tries to clarify many of the legal implications of EHR vendor contracts, and discusses the realities of the “gag clauses.”

According to Kenyon, gag clauses in EHR vendor contracts do not necessarily prohibit users and researchers from offering negative feedback regarding their EHR systems. However, as soon as users or researchers include a screenshot of an EHR screen in their critique, they are breaching the “gag clauses” that actually deal with protecting intellectual property.

Kenyon states that many EHR vendor contracts include clauses that prohibit users from publically sharing screenshots of the EHR while reviewing the product without vendor permission. These clauses exist to protect the intellectual property of EHR vendors. However, they are actually quite vague and unclear, giving vendors the power to prohibit potentially vital research that could improve the EHR for patient safety.

“The true ‘gag clause’ problems with EHR vendor contracts appear to be related to the confidentiality and intellectual property terms, which are overbroad and unclear, and limits on ‘authorized uses’ of the EHR, as those terms apply to research and reporting that requires access to the EHR and use of screenshots,” she writes.

Furthermore, when researchers are able to access screenshots to share information for system improvement, vendors are given a high level of control regarding what system information is released. This potentially prevents unbiased information from being published, hindering the improvement process.

“As long as researchers must ask vendors for permission to do research or to publish screenshots, and as long as vendors can deny permission for any reason, including not liking the results, there is a serious danger that research will be designed and findings presented in ways that garner vendor permission,” she writes.

Kenyon points out that these clauses exist to protect the intellectual property of EHR vendors. The vendors are concerned that should information regarding the look and functionality of their software be released to the public, other vendors may steal these features. This would cause vendors to lose “competitive advantage,” Kenyon says, and would hurt the business of the EHR industry.

Kenyon says that many EHR users state that this fear of vendors is not entirely well-founded considering the ease with which competitors are able to gather information regarding a certain EHR.

“...it is not that hard to discover what different EHRs look like. For vendors hoping to improve their EHRs by ‘stealing’ from others, waiting for research with screenshots to be published would be an exceptionally inefficient way to do so,” she writes.

Furthermore, many physicians maintain that no price can be put on the safety of patients, Kenyon reports.

Kenyon maintains that under existing contracts, the provisions made to protect intellectual property are not functional for researchers. To increase patient safety while using EHRs, different standards are going to have to be implemented, Kenyon suggests.

“Stakeholder groups for patient and EHR safety, including parties to EHR contracts, should share interests in making health IT safety-related research and reporting as easy as possible,” Kenyon explains. “EHR vendor contracts should reflect as much consensus on these issues as is possible.”

She continues to provide suggestions for the construction of future EHR vendor contracts, stating that there should be no gag clauses, but rather clauses that encourage research and encourage reporting of adverse outcomes. By identifying these areas for improvement in EHR vendor contracts, research and adverse event reporting may potentially help increase patient safety.

October 1 has come and gone, and nearly two weeks in to ICD-10 compliance most of the healthcare industry is relatively mum on the transition to the newer clinical diagnostic and procedural code set. More than likely, healthcare organizations and professionals are busy enough adapting to ICD-10 and its more specific set of codes.

That’s not to say some are not speaking out or in support of ICD-10 compliance.

Two recent weekend reports in the Florida’s Crestview News Bulletin and Maine’s Bangor Daily News paint two very different pictures of ICD-10 compliance at the two-week mark.

Apparently, some physician practices in the Florida panhandle are going through the motions in adapting to the federal mandate for ICD-10 compliance which began back on October 1. Brian Hughes reports that medical offices are encountering difficulties with the code set.

“Large practices and medical companies, such as Peoples’ Home Health, usually have coders on staff. Their only job is to enter the numbers into billing records and insurance reimbursement forms,” he writes. “For smaller offices like Dr. Herf’s and Mir’s, the increased coding tasks take away staffers’ time with patients.”

Betty Jordan, the manager of physician practice of Abdul Mir, MD, views ICD-10 as more of a hindrance than a help.

“It requires so much extra work. If my doctor treated someone for rheumatoid arthritis, there’s hundreds of codes. It’s got to be specific,” she told the Crestview News Bulletin.

“It is horrible for a primary care doctor,” she further revealed. “For a specialist, they deal with the same things over and over. For us in family practice, we see all kinds of things. It’s overwhelming.”

For an administrator at the practice of David Herf, MD, the challenge of ICD-10 compliance is the result of increased specificity being married to an increase amount detail.

“It’s really, really detailed,” Andrew Linares told the news outlet. “Instead of just saying, ‘cyst of the arm or trunk,’ you have to get really specific.”

For one of the physician practices, adapting to ICD-10 is akin to learning a whole new language.

The climate in Maine appears much sunnier regarding ICD-10 compliance. Jen Lynds reports high levels of preparation among Maine healthcare organizations and professionals leading to a smooth transition.

“Health care providers across the state began working Oct. 1 with a new system of medical codes that has them describing illnesses and injuries in more detail than ever before, and officials from hospitals and medical associations said earlier this week that they are prepared for the challenge,” she writes.

According to Gordon H. Smith, the Executive Vice President of the Maine Medical Association, complaints are scarce as are ICD-10 implementation delays. Director of Communications for the Maine Hospital Association reports the same situation.

That being said, leadership at Eastern Maine Medical Center are preparing for transition-related productivity decreases for coders and billers used to the previous code set. However, things are still proceeding as planned.

“Our transition to ICD-10 has gone very smoothly here at Eastern Maine Medical Center,” Director of Coding and Clinical Documentation Improvement Mandy Reid told the Bangor Daily News. “We are using nine contract coders through outside vendors to support the ICD-10 go-live, and we secured them several months ago to be prepared. We also have added three positions in the outpatient area to help support growing volume, as well as ICD-10 coding.”

The lesson learned so far is that a clinical practice’s ability to invest in ICD-10 preparation (e.g., training) correlates to its present-day confidence in ICD-10 compliance.

Although the Office of the National Coordinator for Health IT (ONC) recently released itsInteroperability Roadmap, the American Academy of Family Physicians (AAFP) does not believe that is enough to achieve nationwide EHR interoperability in a timely manner.

In a recent letter addressed to National Coordinator Karen DeSalvo, MD, MPH, MSc, AAFP’s Board Chair Robert Wergin, MD, FAAFP expressed his and the organization’s dismay at the slow progress of nationwide interoperability.

“Our members and the AAFP are very concerned with the very slow progress toward achieving truly interoperable systems. Furthermore, we strongly believe there is need for increased accountability on industry and decreased accountability on those who are using their inadequate products,” wrote Wergin.

According to Wergin, care coordination, patient engagement, and population health management all need greater support through increased interoperability. However, at the rate the healthcare industry is moving with regard to interoperability, those goals are not expected to be achieved soon. To change this course, Wergin says the industry needs more action rather than more planning. Additionally, providers and organizations that are playing their parts in increasing interoperability need more support.

“We need more than a roadmap; we need action. First, it is our belief that without significant changes in the way health care delivery is valued (e.g. paid) then it will not matter how many standards are created, how many implementation guides are written, how many controlled vocabularies are fortified, or how many reports are created; we will still struggle to achieve interoperability. Any roadmap for interoperability needs to ensure payment reform toward value based payment, in addition to the technical work. This aligns the health care business drivers to the achievement of true interoperability.”

Wergin argued that certified EHR systems are a contributing factor for this slow growth toward nationwide interoperability. In 2007, he said, the AAFP was responsible for creating a set of standards for healthcare summary exchange. However, despite the adequacy of those standards, Wergin reported that practitioners still experienced difficulty in exchanging information due to incompetencies of EHR systems. Because the EHR systems cannot interpret the data that is being exchanged between systems, physicians are finding themselves manually inputting data from one system to another.

“Instead, physicians must view the documents on the screen, just as they would a fax, to find the important information. Then they must re-key that information into their EHR if they want to incorporate some of the summary information into the patient’s record,” Wergin explained.

Wergin described an urgent need to transform interoperability. If practices are expected to achievemeaningful use and other incentive-based models, interoperability needs to be a high priority for the health IT industry.

“Everyone including technology vendors, hospitals, health systems, pharmacies, local health and social service centers and physicians, must come together as a nation to achieve the interoperability levels laid out in this roadmap at a more rapid pace,” Wergin wrote.

Comparing the push for interoperability to President Kennedy’s push to get to the moon, Wergin states that the health IT industry should be able to achieve its goals in the same 10-year timeframe that Kennedy did. By 2019, Wergin stated, the entire healthcare industry should be using completely interoperable systems.

“We should be much closer to our goal and it should be accomplished within ten years (2019),” Wergin wrote. “The AAFP is dedicated to continue our work to achieve interoperability which is fundamental to continuity of care, care coordination, and the achievement of effective health IT solutions.”

Epic Systems is in the driver's seat compared to other ambulatory EHR vendors and poised to take control of an even larger portion of the outpatient EHR market, according to a recent survey of more than 170 ambulatory care facilities.

Conducted by peer60, the report shows Epic to control close to 20 percent of the ambulatory EHR market several points ahead of its main competitor Cerner Corporation, which owns less than 15 percent.

The authors of the report base their predictions for Epic's growth on the perceived market dominance of the Wisconsin-based EHR vendor — that is, "mindshare." Epic and Cerner are neck and neck among ambulatory care facilities in this area, hovering around 32 percent.

"As has been the case in past years, Epic’s and Cerner’s aggressive positions will continue to gobble up pieces of the ambulatory pie currently occupied by vendors that have struggled to stay relevant in this space," the report states.

Also likely to make gains are athenahealth and eClinicalWorks whose mindshare ranges between 14 and 20 percent:

The other half of the market share and mindshare story and equally impressive is athenahealth’s and eClinicalWorks’ significant mindshare figures at approximately eight and five times their current market share in the overall ambulatory EHR market, respectively. This indicates these vendors are finding significant ways to positively connect with providers.

According to the authors, the disparity between market share and mindshare indicates a need for EHR vendors to improve their standing among ambulatory care providers, a caveat being that EHR vendors focusing on independent facilities have less to lose because many ambulatory centers base their EHR selection on hospital EHR selection.

For these independents, Epic and Cerner trail NextGen based on market share, the latter holding close to 20 percent of the marketplace. As for mindshare, NextGen's prospects are not good "considering they occupy no space in the future plans of independent ambulatory providers," the authors contend. Meanwhile, eClinicalWorks is set to make major gains among these ambulatory care settings well ahead of both Epic and Cerner.

Factoring in to future ambulatory EHR selections will be EHR vendor recommendation scores from providers. On average, ambulatory providers are more likely than not to recommend their current ambulatory EHR technology to others — 6.2 out of 10. The scores for individual EHR vendors is not made public, but five vendors scored above the 6.2 mark with one scoring as high as 9.3.

What will likely influence ambulatory EHR selections are solutions to the top challenges for provider EHR users. The top EHR challenges are missing EHR functionality (55%), lack of EHR usability (42%), and support of a practice's strategic objectives (30%).

Despite these responses, the ability of EHR vendors to make inroads in the ambulatory care setting will be difficult. A vast majority of respondents (85%) are not actively looking for EHR replacement technology. This is the case for both hospital-owned and independent ambulatory facilities.

It happened. The switch flipped and on Oct. 1, our healthcare system went from around 14,000 diagnostic codes to 68,000 codes with the final implementation of ICD-10. No “Y2K”-style catastrophe. No computer system meltdowns.

We will now be watching for the long-term effects of this change. Will the processing of payments for healthcare services in the United States be adversely affected by this transition? We won't know the answer to this for some time.

As the EHR guru for my private practice, I have been responsible for the transition on the local level. This means making sure that our software is up to date and ready, and our various billing documents and their associated procedures are ready to communicate ICD- 10 information to our billers.

Additionally, as an EHR "superuser" on the medical staff of my community hospital, I watched transition issues and steps very closely in preparation for the transition. I have to say that I have been pleasantly surprised with both the administration of the hospital, as well as with the IT folks and on-site EHR vendor staff, in making this transition as painless as possible.

I have written before about how, in this phase of EHR development, the EHR has focused on the needs of the system (i.e. meaningful use, billing, etc.) and not the needs of the providers in making the process of documenting our care as smooth and easy as possible. In the most recent major upgrade to the industrial strength EHR system, significant strides forward were achieved in making the providers’ lives easier.

The first was to make customizable specialty view landing pages that facilitated EHR use to document patient encounters in a very linear and intuitive process. I have been documenting patient care with the EHR for more than three years now, and this one change was a huge step forward in using my time efficiently on rounding in the hospital.

The second major change in the hospital's EHR was simplifying the coding tool. From within the landing page, you just click on diagnosis, and start with a simple search term like "breast neoplasm." This immediately presents you with vertical lists in columns, from left to right. As you make choices in the columns (e.g., disease specifics, anatomical location, laterality, etc.) the choices rapidly narrow, and the coder lets you know through visual clues when there is sufficient information for a complete ICD-10 code. Whoever designed this deserves a medal.

I have worked with physicians and showed them how to use the landing page, as well as the diagnosis tool, and early and late adopters have both been able to adjust their way around the software quickly - indicating a sign of intelligent, user-friendly design.

I have been told by the vendor support staff that the new focus on supporting the needs of the providers will bring tablets and tools to the floor of the hospital, which will make the end user experience much better, time efficient, and useful. This has not happened just yet – one step at a time - but I remain bullish on the promise of the EHR.

I'm hopeful that the world of the EHR is moving to a new phase; a phase that focuses more on making the processes of documenting patient care easier, faster and more intuitive. Good data flows uphill, and makes the other outputs of the EHR more cohesive. The coming weeks, months, and years will ultimately tell the tale of this transition to ICD- 10, but I’m hopeful that it will ultimately give us the information and data we need to make a difference in the healthcare system and in the lives of our patients.

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